Virtual RetreatsONLINE 2-DAY INTENSIVE 

Refer to the Program Section of our Website for current dates of Virtual Programs

Virtual Program Consents Page 1 of 3

BridgePoint Center for Eating Disorders Virtual Care Informed Consent

I, (name) _______________________________________________ , agree to participate in the residential programming offered by BridgePoint Center Inc. (Operating as BridgePoint Center for Eating Disorders and hereinafter referred to as "BridgePoint"), of Milden, Saskatchewan.

I HEREBY REMISE release and forever discharge BridgePoint and the Saskatchewan Health Authority from any liability, actions, suits, damages, claims or judgments that may result from any injury to my property or person for any reason whatsoever, including but not limited to any act or omission of BridgePoint or its agents, whether negligent or otherwise. I AM VOLUNTARILY participating in virtual programming offered by BridgePoint. I am signing this document of my own free will.

Due to the ongoing risk of the COVID-19 virus, BridgePoint Center has canceled all in-person groups until we get approval from SHA to resume services. In light of the COVID-19 precautions, we have been working hard to develop alternative ways to provide support to our community. Online and in-person group therapy and educational workshops are a unique environment in which a group of people who are likely experiencing similar difficulties come together to both give and receive help from one another. BridgePoint Center attempts to create an environment where honest, interpersonal exploration will occur that will benefit all members. To create this environment, certain guidelines need to be agreed upon by each participant. As this is a new pilot project, spots are limited.

CONFIDENTIALITY Groups are effective because individuals feel safe to share private information in a confidential atmosphere. Every member of the group must agree to uphold the confidentiality of the therapeutic setting.

Members agree to keep the names and identities of other group

members confidential.

All group/workshop materials and content are confidential.

Please do not share, photocopy, record, screenshot, video tape or

audio tape sessions unless agreed upon for therapeutic purposes.

ATTENDANCE Group therapy is successful (as is any form of therapy) when there is regular attendance on behalf of the participants. If you cannot attend a group meeting, please email us to let us know as soon as possible. In your message please also indicate whether or not it is permissible for us to share why you are absent. Please arrive on time. If you miss and cancel late (less than 24 hours ahead of time) 2 times, we reserve the right to remove you from the group.

ACTIVE PARTICIPATION Members of effective groups actively share thoughts, reactions, and feelings during group meetings as a way of increasing their self-understanding and contributing to the personal growth of other

members. To support that goal, facilitators will strive to establish and maintain a climate of respect within the group. Each member will undoubtedly share in different ways and be comfortable with different levels of disclosure. It is requested that as a participant you share what is comfortable and actively listen and attend to other group members. Participation does not necessarily mean talking. It can also mean listening to what other members have to say. No one will ever be forced to share anything that they are not comfortable sharing.

WITHDRAWAL Members will let the group know in advance if they are leaving the group. Group participation is voluntarily. If you or the facilitator(s) determine that the group is not serving your needs, you will be referred to other options.

ONLINE SESSIONS All of BridgePoint’s online workshops and groups are conducted using the Pexip, which is an approved platform by Saskatchewan Health Authority. Pexip is also committed to protecting personal health information consistent with the requirements of the Personal Health Information Protection Act, 2004. To learn more about Pexip’s commitment to privacy, visit: https://https://www.pexip.com/security/security-data-protection otn.ca/about-us/privacy/

RESEARCH Participant health and EDQLS data may be used for research purposes with non-identifiers. You can refuse this prior to entering the program or can be withdrawn at any date.

Should it be discovered that you are in breach of any of the policies above, the facilitator(s) and/or other group members may ask that you terminate your participation in group therapy.

In exchange for allowing me to participate, I hereby waive and covenant not to sue, and further agree to indemnify, defend, and hold harmless, BridgePoint Center Inc. and its officers, directors, employees, contractors, and volunteers (collectively, the “Waived Parties”), from any and all liability, claim(s), demand(s), cause(s) of action, damage(s), loss or expense, including court costs and reasonable attorney’s fees of any kind or nature whatsoever (“Liability”) which may arise out of, result from, or relate to my participation. I further agree that if, despite this Agreement, I, or anyone on my behalf, make a claim for Liability against any of the Waived Parties, I will indemnify, defend, and hold harmless the Waived Parties from any such Liability which may be incurred as a result of such a claim that I might have against the Waived Parties or anyone associated with the educational support group.

I understand all of the above and agree to the above terms.

Participant Name: ________________________________________

Participant Signature: _____________________________________

Date: __________________________________________________

Virtual Program Consents Page 2 of 3

BRIDGEPOINT CENTER VIRTUAL PROGAMMING COMMITMENT

Virtual group programs require a sense of community to operate effectively. It is the intention of BridgePoint Center to create a safe, nurturing, healing environment for program participants and team members. The following boundaries and walls were developed to promote a safe residential experience in community.

Boundaries

Boundaries are guidelines for behavior, and imply a degree of flexibility.

1. I will participate in the full program schedule. 2. I understand that I am required to have my video and microphone function available and turned on throughout the group

(except while I have my microphone on “Mute”). 3. I will ensure I have a private environment to ensure confidentiality and will use headphones during sessions. 4. I will sign in to the call at least 5 minutes in advance of the session. 5. I will be punctual and understand that late entry may not be permitted once the virtual room is locked. 6. I will practice courteous and responsible behavior. I will demonstrate adequate impulse control by not interrupting a

participant’s process or giving advice. 7. I will not use my cell phone during any group activities (unless for the use of accessing this program). 8. During a virtual retreat, if I choose to leave the program prior to its completion, I agree to consult team.

Walls

Walls provide a firm structure to ensure the safety of individuals participating in BridgePoint programming. 1. Confidentiality at BridgePoint is essential. I will not discuss the experiences of other participants. I will not name or

describe other participants. I will not take pictures of group participants or chats. (“Participants” is all encompassing and includes team).

2. BridgePoint is a place where people of all sizes, shapes, genders, abilities, and backgrounds can gather to celebrate all bodies, support one another as we work toward body acceptance, and build a more inclusive community that values all people. I will preserve this inclusive community by not commenting on anyone’s body image.

3. BridgePoint has a zero tolerance policy for behavior that jeopardizes personal safety. Violent behavior is not tolerated. Violence is defined as verbal, physical, sexual or emotional aggressive behavior. Violence can be, but is not limited to raised voices or tone, sarcasm, threats, comments or mannerisms.

4. I will not consume alcohol, use drugs (including marijuana unless previously approved as medically necessary), or other mind altering substances while attending BridgePoint virtual programming.

5. In order to remain a participant in BridgePoint programming, participants must remain medically and psychiatrically stable during the entire program. Should I feel like I am not able to keep myself safe I will reach out and engage outside resources as necessary (see list attached).

I understand the BridgePoint Center “Virtual Programming Commitment” and agree to abide by BridgePoint Boundaries and Walls as presented. I understand that I am responsible for my own behavior. I understand that BridgePoint team members are available to provide support to me and assist me to continue my personal recovery. Signature of Participant _____________________________ Date____________________________

Virtual Program Consents Page 3 of 3

CONSENT FOR RELEASE OF INFORMATION

SHOULD ANY INDIVIDUAL/AGENCY CHANGE A NEW FORM WILL BE REQUIRED

I, _________________________, BIRTH DATE: ________________, OF ___________________________ (Name) (YY/MM/DD) (Community, Province)

hereby consent to allow BridgePoint Center Inc. (hereinafter referred to as "BridgePoint") to release information from their clinical records:

To: ________________________________________________________________________________

DOCTOR (Name and address of individual and/or agency to receive information)

And: _______________________________________________________________________________ COUNSELLOR (Name and address of individual and/or agency to receive information)

And: _______________________________________________________________________________ PHARMACIST (Name and address of individual and/or agency to receive information)

And: _______________________________________________________________________________ PSYCHIATRIST (Name and address of individual and/or agency to receive information

And: _______________________________________________________________________________

DIETITIAN (Name and address of individual and/or agency to receive information)

And: _______________________________________________________________________________ FAMILY MEMBERS/FRIENDS (Name and address of individual and/or agency to receive information)

And: SASKATCHEWAN HEALTH AUTHORITY (Mental Health and Addictions Services) as required during their partnership with BridgePoint during programming.

_________________________________________________ _______________________________________ Signature of Participant (or Guardian if under 16) Date of Participant Signature

__________________________________________________ _______________________________________ Signature of Witness Date of Witness Signature

This consent will expire only upon written notification, from you (Participant), advising BridgePoint “consent is withdrawn”, and by specifically naming to whom you do not want information released.

VIRTUAL APPLICATION - PART A – Page 1 of 3

Please return completed form as legibly as possible and return to: Admissions, BridgePoint Center

Fax: (306)935-2241 Email: bridgepoint@sasktel.net Box 190 Milden, SK. S0L 2L0 Phone: (306) 935-2240 INCOMPLETE OR ILLEGIBLE APPLICATION FORMS WILL NOT BE PROCESSED

Please note that we are not a crisis line and do not provide any emergency services.

VIRTUAL SUPPORT APPLICATION FOR 2-DAY INTENSIVE ONLINE RETREAT Please note: This is a two-step application process. Once your application is processed, an email will be sent from BridgePoint with the available virtual program dates. Participants will then be required to access the online registration platform to complete enrollment and secure their seat for the retreat. Participants will require access to a laptop or tablet with internet or data service. Due to demand, we ask that participants register for only one program at a time.

Referral Source: ⃝ Self-referral ⃝ Referring Professional Former Health Region: __________________ Referral Contact Info:___________________________________________________________________________________________________________

Applicant Information

Name:

⃝ Male ⃝ Female

⃝ Other ____________

Preferred Pronoun:

DOB: AGE:

Health Card #: Issuing Province: Expiry:

Address:

Box/Street City, Prov Postal Code

Contact Information

Please provide phone numbers where

messages can be left.

Home Phone: Cell Phone: Work Phone:

Email Address:

Preferred Method of Communication: ⃝ Phone Call ⃝ Email ⃝ Other

Safety Contact Which Whom BridgePoint

may share/receive your information.

Name: Contacted in emergency situation or early departure from program

Home Phone

Cell Phone

Relationship: Street Address/City:

Email:

Health Care Provider, Person

or Agency

Doctor: Phone:

Counsellor: Phone:

⃝ BridgePoint is not a medical facility and I will be able to maintain medical and psychiatric stability during programming. This program is not a substitution for medical intervention.

Applicant Signature: _______________________________ Date: ________________

PART A

completed by Applicant

VIRTUAL APPLICATION - PART A – Page 2 of 3

Eating Disorder Behaviours

What eating disorder symptoms or behaviours have you experienced?

Overeating/binging ⃝ None ⃝ Past ⃝ Current Frequency:

Purging (vomiting/laxative use, etc.) ⃝ None ⃝ Past ⃝ Current Frequency:

Under-eating/restricting food intake ⃝ None ⃝ Past ⃝ Current Frequency:

Excessive or compulsive exercise ⃝ None ⃝ Past ⃝ Current Frequency:

Ongoing dieting or calorie counting ⃝ None ⃝ Past ⃝ Current Frequency:

Use of diuretics, laxatives, or diet pills ⃝ None ⃝ Past ⃝ Current Frequency:

Changes in weight during the past year ⃝ Gain ⃝ Loss ⃝ Stable How Much:

Other: ⃝ None ⃝ Past ⃝ Current Frequency:

Daily Reported Food Intake: ⃝ Less than 1 meal/day ⃝ 1 meal/day ⃝ 2+ meals/day (including snacks)

Describe your current experience with food: _________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Years with disorder: _____ Current Diagnosis (self-perspective): __________________ Age first self-diagnosed: ________________

Current Health

Current or ongoing medical or mental health concerns:

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Date of last GP Visit: _____________ Any concerns: _________________________________________________________

Date of last physical: _____________ Any concerns: _________________________________________________________

Amenorrhea ⃝ Yes ⃝ No Date of Last Period: ______________

Have you ever been hospitalized? ⃝ Yes ⃝ No If yes, date of last admission/duration/reason:__________________________

⃝ Diabetes ⃝ Pregnant (#weeks __) ⃝ Substance Use/Dependency ⃝ Mobility Issues ⃝ CPAP Machine

Special Accommodation Requests:__________________________________________________________________________________

⃝ Appointments during programming ________________ (must be approved and arranged prior to admission.)

⃝ Medical Marijuana Usage (must be approved for use onsite prior to admitting. Send prescription and licence with application.)

⃝ Allergies (List type/severity/Tx) _____________________________________ ⃝ Epi-pen

⃝ Service Animal Type: _____________ Contact BridgePoint to request approval and for separate application. Cannot attend without prior approval.

What plays an integral part in your recovery? What other supports or resources would be helpful? ______________________________________________________________________________________________________________________________________ ___

_________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________ ___________________

_________________________________________________________________________________________________________________________________________

Current Supports: ⃝ Mental Health Team ⃝ Psychologist ⃝ Therapist

⃝ Psychiatrist ⃝ Dietitian ⃝ Day Program

⃝ Self-help groups ⃝ Group Home ⃝ Others

What other treatments have you accessed in the past? Or since you were last here? What are you working on with your supports? _________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________ ________________

_______________________________________________________________________________________________________________________________________

PART A – Page 3 of 3

PARTICIPANT NAME: DATE:

Check all that apply:

⃝ Depression ⃝ Anxiety ⃝ Hoarding ⃝ Obsessive compulsive ⃝ Other:

⃝ Social isolation ⃝ Manias, mood swings ⃝ Stealing/shoplifting ⃝ Memory problems ⃝

⃝ Chronic thoughts of suicide ⃝ Perfectionism ⃝ Sexual compulsivity ⃝ Substance use/addiction ⃝

⃝ Suicide attempts (past year) ⃝ Attention deficit disorder ⃝ Bipolar ⃝ Borderline personality ⃝

⃝ Trauma/PTSD ⃝ Schizophrenia ⃝ Trichotillomania ⃝ Sensory disorder ⃝

⃝ Gambling addiction ⃝ Shopping addiction ⃝ Dissociative identity Other: Other:

Personal History of Known Abuse/Trauma

⃝ Physical ⃝ Verbal ⃝ Emotional ⃝ Sexual ⃝ Neglect

⃝ Adverse Childhood

Events

⃝ Financial ⃝ Spiritual Other:

_______________________________________________________________________________________________________________________________________

Personal History of Self Harm/ Suicide Attempts

⃝ Past history of Self Harm ⃝ Present Self Harm ⃝ No history of Self Harm ⃝ Past Suicide Attempt ⃝ Recent Suicide Attempt (2

months)

Quality of Life- Where has the eating disorder had the greatest impact on your life?

⃝ Employment ⃝ Relationships ⃝ Housing/Food Insecurity

⃝ Financial ⃝ Spiritual

⃝ School ⃝ Social/recreational ⃝ Legal ⃝ Other

External Agency Diagnosis (DSM-5 Feeding and Eating Disorders): Check one below (most recent diagnosis)

Age diagnosed: _____ ⃝ Anorexia (AN) ⃝ Bulimia Nervosa (BN) ⃝ Binge-Eating Disorder (BED)

⃝ Other Specified Feeding or Eating Disorder (OSFED)

⃝ Unspecified Feeding or Eating Disorder

⃝ No formal diagnosis Other:

Occupation: _______________________________ Highest Level of Education: _________________________

⃝ Employed ⃝ Unemployed ⃝ Unemployed ⃝ Disability – SAID ⃝ Disability – work plan ⃝ Student

Marital Status: _________________________ Children: Age/Sex ______________________________________

Family of Origin (Is there anything about your family that would be important for us to know?) _________________________________________________________________________________________________________________________________________

Internal vs. External Motivation Out of 100%, what percentage of you is motivated to be here for yourself vs others? Yourself ____% Others _____% (adds up to 100%)

What strengths do you bring with you to BridgePoint and your recovery? ie. Humor, perseverance, tenacity, stubbornness, etc

_________________________________________________________________________________________________________________________________________

Client Identified Resources: Who or what plays an integral part of your recovery? i.e pets, spirituality, music, friends, etc?

_________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________ ___________________

_________________________________________________________________________________________________________________________________________

What other information would you like us to know? Please explain: ____________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________ ___________

© C.E. Adair; G. Marcoux

EDQLS

Quality of Life Scale

Version 1.0 released May 2008

Quality of life is the sense of satisfaction that a person has with her/his life and how much she or he enjoys various parts of it

Here is an example item:

Strongly Disagree

Disagree Neither

Agree or Disagree

Agree Strongly Agree

1. I enjoy going to the movies 1

3 4 5

2

Instructions:

• Inside are 40 questions about how you feel about the quality of your life.

• Please rate the items according to your feelings, not how you think others might expect you to answer.

• Responses will be different for different people; there are no right or wrong answers.

• Answer based on your first impression. Even if you think an item doesn’t apply to you, give it your best guess.

FULL NAME: __________________________ Date Completed: __________________ : COMPLETED FORM IS REQUIRED AS PART OF VIRTUAL PROGRAMING APPLICATION

(Data will be anonymously used for research purposes by assigning a Research ID and nameswill be redacted. )

© C.E. Adair; G. Marcoux

1

Think about how you’ve felt in the LAST WEEK, and then circle the response that best fits for you.

Strongly Disagree

Disagree Neither

Agree or Disagree

Agree Strongly Agree

1. I have fun with others 1 2 3 4 5

2. I feel I don’t have a life 1 2 3 4 5

3. I have a very close relationship with at least one best friend or partner

1 2 3 4 5

4. I have trouble concentrating 1 2 3 4 5

5. My health is more important to me than my physical appearance

1 2 3 4 5

6. My life is full of worry right now 1 2 3 4 5

7. I show my true self to others 1 2 3 4 5

8. I have lots of rules about food 1 2 3 4 5

9. I have lots of energy 1 2 3 4 5

10. I feel connected to others 1 2 3 4 5

11. I get satisfaction from my main activity (e.g. school, work)

1 2 3 4 5

12. I think about food constantly throughout the day 1 2 3 4 5

13. I see positive things in my appearance 1 2 3 4 5

14. I can allow myself to relax 1 2 3 4 5

15. I skip meals on purpose 1 2 3 4 5

16. I have fights with my family members about food or eating

1 2 3 4 5

17. Every day is a struggle 1 2 3 4 5

18. The number on the bathroom scale is very important to me

1 2 3 4 5

19. I turn down opportunities to go out with friends 1 2 3 4 5

20. I can focus on things other than food 1 2 3 4 5

Please turn to

the next page

© C.E. Adair; G. Marcoux

2

Strongly Disagree

Disagree Neither

Agree or Disagree

Agree Strongly Agree

21. I feel hopeful about the future 1 2 3 4 5

22. People don’t understand me 1 2 3 4 5

23. I don’t go out with friends if I feel bad about my body

1 2 3 4 5

24. I enjoy participating in different activities, not just exercise

1 2 3 4 5

25. I’m constantly trying to fix my body 1 2 3 4 5

26. I am able to see good qualities in myself 1 2 3 4 5

27. I have plans for my future 1 2 3 4 5

28. I feel understood by someone in my family 1 2 3 4 5

29. Thoughts about food and eating dominate my life 1 2 3 4 5

30. I put myself down a lot 1 2 3 4 5

31. I feel self-conscious about my body around others

1 2 3 4 5

32. My sleep is restful 1 2 3 4 5

33. I feel comfortable eating in front of people 1 2 3 4 5

34. The eating disorder affects what I can do every day

1 2 3 4 5

35. I do things I normally wouldn’t do because of my eating disorder

1 2 3 4 5

36. I can consider my own happiness when making choices

1 2 3 4 5

37. I feel like nothing I ever do is quite good enough 1 2 3 4 5

38. I’m obsessed with my weight or my body shape 1 2 3 4 5

39. The eating disorder has taken over my life 1 2 3 4 5

40. I feel physically cold 1 2 3 4 5

Keep up the good

work, only one

more page to go

© C.E. Adair; G. Marcoux

3

In this last section please rate how IMPORTANT the following areas of life are to YOU.

Global Quality of Life Rating: Finally, please rate your overall quality of life in the last week on a scale of 1 to 10, where 1 is Poor and 10 is Excellent

1 2 3 4 5 6 7 8 9 10

Very Unimportant

Unimportant Neither

Important or Unimportant

Important Very

Important

School/Work 1 2 3 4 5

Family and Close Relationships 1 2 3 4 5

Relationships with Others 1 2 3 4 5

Your Future 1 2 3 4 5

Your Feelings 1 2 3 4 5

Your Appearance (How you look) 1 2 3 4 5

Your Leisure (Free time activities) 1 2 3 4 5

Your Values and Beliefs 1 2 3 4 5

Thinking and Concentrating 1 2 3 4 5

Your General Physical Health 1 2 3 4 5

Your Psychological Health 1 2 3 4 5

Your Health Related to Food & Weight 1 2 3 4 5

If there are any other areas of your life that are not listed in these 12 above please specify and rate

1 2 3 4 5

1 2 3 4 5

Thanks so much for your

answers, have a great day!

The EDQLS is in the public domain and may be used for research and treatment purposes without charge and with permission of the authors/copyright holders (C.E.

Adair and G. Marcoux). It may not be used for any commercial purpose. The authors/copyright holders must be acknowledged as such in any reports, publications or

presentations in any format. Other not-for-profit and publicly funded programs and non-commercial research users may use the EDQLS at reduced cost. Full license fees will apply to all commercial and for-profit uses. Registration is required for all uses; please contact ceadair@edqls.com